About the Keep Well Clinic Program

At Don Medical Clinic we have a strong belief that early intervention and prevention for all age groups will have a profound impact on long-term health outcomes.

Our goal is to assist you to keep well, active and out of hospital, not just treat you when you are sick. By detecting disease or risks early we can work with you to minimise your hospital admission risks.

The Keep Well Clinic Program incorporates chronic disease management programs and Health Assessments. We will utilise Medicare chronic condition item numbers where approriate to minimise your out pocket expenses

The Keep Well Clinic program promotes annual health assessments for all age groups.

In addition to this we promote establishment of "Person Centred" GP Chronic Condition Management Plans (GPCCMP) for all patients with chronic conditions.

GP Chronic Condition Management Plans

There has been a change in the Medicare items for Chronic Disease from July 1st, 2025. They are now classified as "GP Chronic Condition Management plans (GPCCMP).

Where a patient has a chronic condition and meets Medicare criteria, then they maybe eligible for a GPCCMP. The new changemeans there is a bit less paperwork for eligibility and reviews. The GPCCMP is to develop a Care Plan that you and your doctor can use to tailor your health care to meet and plan your current health needs.

These plans should be reviewed every 3+ months with your GP to get the best benefit for yourself. All patients with the new plans will be eligible to access up to 5 visits annually (calender year) to an approved allied health professional, which are partly subsidised by Medicare if your GP refers you to one of the services. In addition to this, anyone with a GPCCMP can also access up to 5 Practice nurse subsidised visits with our Don Medical Clinic nurse. These are useful if you GP would like some Nurse monitoring of certain things (eg, BP checks, follow up phone calls, immunisations wound care etc)

If you are unsure as to whether you are eligible for these

Chronic Disease Management Fact Sheet

INCA EVO

Don Medical Clinic utilises and electronic care panning tool called INCA EVO. This assists in developing your plan initially and when care palns are reviewed to make it a "living document" that is adjusted as your health goals are reviewed and updated. This program is utilised through our secure computer server and only assists in producing the correct documentation and assist witj Medicare compliance. You will be provided with a copy of your GPCCMP when required.

In Australia, 10 common chronic conditions contribute to

66% of the burden of disease

52% of hospitalisations

89% of deaths

Source: Australian Institute of Health and Welfare (2023) Chronic conditions and multimorbidity, AIHW, Australian Government, accessed 25 January 2024.

The 10 conditions are: arthritis, asthma, back problems, cancer, chronic kidney disease, Chronic Obstructive Pulmonary Disease (COPD), diabetes, mental and behavioural conditions, osteoporosis or osteopenia, and selected heart, stroke and vascular diseases (based on underlying or associated causes of death).

Health Assessments

Don Medical Clinic has a strong belief that early intervention for any age group will have a profound impact on long-term health outcomes. The Keep Well Program promotes annual health assessments for all age groups.

The health assessment is tailored to individual needs and is age, sex and culturally dependent, as this brings different levels of risk of disease for the individual.

Where appropriate blood and urine tests are organised before the check up. Other tests such as ECG or breathing tests are done at the time of the visit depending on the individual risk factors.

The visit will involve a session with our practice nurse for 30-40 minutes and then a review by the doctor.

There are however specific programs for

Indigenous Australians. (Annually for all ages from birth (Bulk Billed)

40-49 year olds at high risk of Diabetes (every 3 years from age 40 - 49 IF high risk of developing diabetes (Fees may apply))

Womens Menopause and Peri-Menopause Health Assessment (item 695- Fees may apply)- Annually

45-49 year olds at risk of chronic disease - a one off assessment (Fees may apply)

Patients aged 75 years of age and onwards - Annual from age 75 (Bulk Billed)

Patients with Intellectual Disablities - (Annually - Bulk Billed to Medicare)

Heart Health Assessments (ages 30 - 74) - Annually if no recorded heart disease (Private or concession fee applies with Medicare rebate)

Former Australian Defence Force Personnel - (once only following discharge Bulk Billed)

Refugees - (Once only - Bulk Billed)

For more information and for details around cost please call reception during business hours on 6441 5299

or email to make an appointment